The Centers for Medicare and Medicaid Services (CMS) has announced the finalized rule for the Radiation Oncology Alternative Payment Model (RO-APM), which is scheduled to be implemented on January 1, 2021.  According the CMS, the model is intended to “modernize and improve care and payment for radiotherapy services” while saving approximately $250 million over the five-year program.

The 199 core-based statistical areas (CBSAs), which were randomly selected and account for 30 percent of all Medicare radiotherapy episodes, are listed below.

Under the program, participants will receive a fixed, prospective payment for 16 cancer types that is intended to cover RT services furnished in a 90-day episode, replacing the long-standing fee-for-service reimbursement system.  The new model applies to hospital-based and freestanding radiotherapy programs and will pay a standard national base payment irrespective of the setting in which care is delivered.

Payment for breast cancer radiotherapy rose 3.4 percent in the final rule compared to the proposed rule, which was issued in July 2019.

Base Rate for Breast Cancer (ICD 10 C50.xx, D05.xx)

Rate Adjustments to Focus on Improving Cost Efficiency, Patient Satisfaction

CMS will adjust base rates to account for various factors, including traditional and new performance metrics that the agency believes will contribute to more efficient, high quality care with high levels of patient satisfaction.  For example, adjustments will be made annually based on performance compared to historical experience of Medicare spending on participant’s episodes of care.  Additionally, (beginning in Year 3) adjustments will also be made based on patient experience using a new CAHPS® Cancer Care Survey for radiation oncology.

Breast RT Impact #1: Fixed Reimbursement Irrespective of Technology, Fractionation Schedule

In radiation oncology, which uses multiple treatment modalities and techniques to deliver treatment, the change essentially provides equal reimbursement based on a patient’s diagnosis regardless of the technology and fractionation schedule used.

Breast RT Impact #2: Programs Incentivized to Shift to More Cost-Effective, Efficient Treatments While Maintaining Quality

The landmark shift in radiotherapy reimbursement is expected to compel cancer programs to re-evaluate how patients are treated.  In breast cancer radiotherapy, for example, treatment can be delivered using external beam radiation (conventionally fractionated or hypofractionated), brachytherapy (interstitial or intracavitary) and proton therapy.  These approaches require varying levels of time and resources to be delivered and reimbursement varies widely.

CMS based the national payment rates on a review of historical Medicare spending on radiation therapy services from 2015 to 2017.  Xcision analysis of the data on breast cancer radiotherapy reimbursement found that, on average professional fees for brachytherapy, 3D-CRT, IMRT and proton therapy fell below the newly established national base payment rates.  Technical fees for conventionally fractionated 3D-CRT, IMRT and proton therapy were significantly below the new base rates.

Breast RT Impact #3: GammaPod S-PBI Offers a New Option Aligned with RO-APM

The GammaPod™ system for Stereotactic Partial Breast Irradiation (S-PBI) from Xcision Medical Systems, which provides a full course of noninvasive treatment in 1 to 5 fractions for patients with early stage breast cancer, aligns with the goals of the new RO-APM.

By reducing the number of treatment fractions and required health care resources needed to deliver care, programs may benefit from offering this important new treatment option that is designed to deliver high quality treatments more efficiently while offering high levels of patient satisfaction.

Note: The statements in this article are solely those of the authors and do not necessarily reflect the views or policies of the Centers for Medicare & Medicaid Services (CMS).

199 Core-Based Statistical Areas (CBSAs) Selected for Mandatory Participation in RO-APM

Xcision analyzed the approximately 9,000 zip codes and mapped them to the corresponding CBSAs.  The table below shows the 199 CBSAs in which radiotherapy programs will be required to participate in the RO-APM. 

Source: Xcision Medical Systems analysis of CMS Zip Code Data, September 21, 2020. 

Source: Xcision Medical Systems analysis of CMS Zip Code Data, September 21, 2020.